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Anabolic steroids and dependence.

The illicit use of anabolic-androgenic steroids (AS) has become a prominent public health issue in recent years. Scandals about the positive drug tests of Olympic and elite athletes have been joined by concern about noncompetitive bodybuilders, gym-goers and adolescents turning to AS use to enhance their appearance and performance. While prevalence is difficult to determine accurately, a recent review concluded that use has "increased significantly over the past three decades." Most U.S. surveys have been of adolescents; overall they indicate that 3%-12% of male high school seniors have used steroids at some time. (1) In Australia, the 1998 National Drug Strategy Household Survey round that 0.2% of those surveyed had recently used AS for non-medical purposes. (2) Of Sydney gay and homosexually active men surveyed for the Sydney Men and Sexual Health study in 1996, 0.7% reported recently using steroids non-medically. (3)

Professional literature and research on AS use has focused on themes such as prevalence of use, the deleterious physical and psychological consequences of use, and characteristics of users, especially predictive and risk factors. One of the commonly mentioned adverse psychological consequences is dependence, as studies have found that significant numbers of users find it difficult to stop AS use despite negative effects, in part because of disabling withdrawal symptoms. For some researchers it can simply be declared that AS are a "widespread, addictive and dangerous substance." (4) However, the status of AS as dependence-producing substances is subject to debate. Unlike "classic" drugs of abuse, they do not produce immediate pleasure, euphoria or intoxication, and this lack of psychoactive effect brings into question their addictive potential. In the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR), AS problems are included under the category "other (or unknown) substance-related disorders," which leaves open the possibility that a steroid dependence syndrome and a withdrawal syndrome exist, without stating that they do. (5) In contrast, the World Health Organization's international classification of diseases places AS in the same category as laxatives, antidepressants and over-the-counter painkillers: abusable but non-dependence-producing substances. (6) In the United States, legislation passed in 1990 placed AS on Schedule III of the Controlled Substances Act. This means they are classified in law as substances with "a potential for abuse that may lead to either low to moderate physical dependence or high psychological dependence." However, this change was opposed by the American Medical Association, which argued that abuse of steroids had not been shown to lead to dependence. (7)

It is commonly argued that what is required for the issue of AS dependence to be resolved is more knowledge about the neurochemical effects of AS and the mechanisms of reinforcement that lead to continued use. While research into the mechanisms of AS will no doubt produce valuable information and insights into patterns of use, the question of dependence seems likely to remain unresolved and contested. This is because the irresolvability is due as much to ambiguities and tensions in the concept of dependence as it is to lack of understanding of AS. Therefore the debate about AS dependence is noteworthy not only for its specific concerns, but because it highlights broad issues about the nature of substance dependence and understandings of compulsive behavior. A substantial body of literature examines medical models of addiction as historically and culturally specific concepts, both emerging from and reproducing particular understandings of freedom, the self and consumption. (8) While not rehearsing these arguments, this paper draws on this critical approach to examine a specific example of how current definitions of dependence produce difficulties when applied to a particular substance. In particular, it focuses on the tension between the emphasis on symptoms exhibited or reported by the individual as the defining signs of dependence and the requirement that these signs be caused by a particular neurochemical mechanism.

Symptoms and mechanisms of dependence

Substance dependence is generally identified on the basis of a combination of observed behavior and reported subjective experiences. As found in the Diagnostic and Statistical Manual (DSM), the central elements of dependence are impaired control over use of the substance and continued use despite harmful consequences. Withdrawal and tolerance are usually present, according to the DSM, but are not found with certain substances. The current version of the DSM is the text-revised fourth edition (DSM-IV-TR), but most of the research on AS dependence has used an earlier edition (DSM-III-R). (9) In the DSM-III-R the user must fulfill three of the nine criteria to be diagnosed as dependent (see list on page 545). Therefore an important aspect of dependence as it is defined in the DSM is that many different combinations and types of symptoms exist, even though the overall pattern of maladaptive use may be similar. Steroid users may demonstrate dependence according to the DSM criteria, but their predicaments and problems may differ significantly from those experienced by other substance users.

However, despite the fact that the muscle-active effects of AS appear quite unlike the psychoactive effects of classic drugs of abuse, case reports in medical and psychological literature do present an easily recognizable picture of drug dependence. Hays et al. describe a 22-year-old weight lifter who complained of depression and inability to stop steroid use. His AS use had begun with cycles of four weeks on and then four weeks off the drug, but feeling he should be "a little bigger" he started decreasing the steroid-free intervals. He also moved from oral steroids to a combination of oral and injectable, until he was combining four different drugs. While taking steroids he lacked energy and felt depressed, and his irritability and temper lead to strained family relations. He developed acne and an apparent heart murmur. During his steroid-free periods he craved steroids, and suffered from lowered self-esteem and anxiety about his body. As Hays et al. report, the case fulfills the DSM criteria for substance dependence. (10) It demonstrates preoccupation with the substance, continued use despite harms, inability to cut down or control use, using more or for longer than expected, and withdrawal symptoms. In another case, of a young AS-using noncompetitive weight lifter, at least six of nine DSM-III-R criteria for substance dependence were met, and the patient experienced suicidal depression and the breakup of his marriage. The course and outcomes of his AS use were described as "strikingly similar" to those observed with alcohol, cocaine and opiate use." (11)

Moving from single cases to larger studies of users, the work of Kirk Brower and his collaborators provides further evidence for the addictive potential of AS. (12) In a 1991 study of 49 male weight lifters who used AS, 57% were classified as dependent because they fulfilled three or more of the DSM-III-R criteria. At least one criterion of dependence was reported by 94% of the sample. The most commonly reported symptom was withdrawal, with the most frequently described symptoms during withdrawal being fatigue, depression, a desire to take more steroids, and dissatisfaction with body image. Other commonly reported criteria were "more substance taken than intended," "large time expenditure on substance related activity," and continued AS use despite problems caused or worsened by use. (13) Other studies employing DSM-III-R criteria have found dependence rates in users ranging from 14% to 69% (the 69% rate was found in a survey of inpatients undergoing treatment for other drug problems in substance abuse programs). (14) Most recently, a study by Midgley et al. of 50 AS users found that 26% fitted the criteria for dependence, a lower rate than Brower's 1991 study but still a significant percentage. (15) Based on these findings, it seems clear that AS use can result in dependence, at least in terms of behavior and clinical phenomenology.

But the question of how AS cause dependence is more contentious. The controversial issue is whether AS are psychoactive and to what extent they produce dependence through "primary" forms of reinforcement--that is, through direct stimulation of the brain. As Brower admits, unless AS can be shown to be psychoactive, they cannot be regarded as dependence-producing according to DSM criteria, which require that dependence be associated with the psychoactive nature of the substance. He sets out four possible mechanisms through which AS produce dependence: (1) primary reinforcement from brain reward systems (including opioid systems); (2) secondary reinforcement from muscular development (including benefits such as increased self-esteem, winning competitions and admiration from others); (3) avoidance of biologically mediated withdrawal symptoms such as those arising from testosterone deficiency and modulation of opioid activity (primary negative reinforcement); (4) avoidance of psychosocially mediated withdrawal symptoms such as depression caused by decreased athletic performance (secondary negative reinforcement). (16)

However, it is difficult to clearly differentiate these forms of reinforcement, at least on the basis of case reports and surveys of users. In a study of high school students, Yesalis et al. note that both increased self-esteem and admiration from others resulting from improved appearance and performance, and altered mood states such as euphoria and well-being act as strong reinforcers in AS use. They also state that psychological components such as the needs and expectations of users are responsible for addictive outcomes in substance use. (17) While the altered mood states suggest primary positive reinforcement (in contrast to the secondary rewards from enhanced appearance and performance), euphoria and well-being could also be the outcome of significant positive changes in physique.

In a 1989 paper titled "Hooked on Hormones?" Kashkin and Kleber postulated that AS have psychoactive effects, withdrawal symptoms and underlying biological mechanisms similar to those of cocaine, alcohol and opioids. They suggested that AS users could develop a sex steroid hormone dependence disorder, "a previously unrecognised drug addiction." However, they concluded that scientific investigation was required to confirm their speculative hypothesis. (18) Writing a decade later, Brower's view is that research so far suggests that a primary reinforcement mechanism is "certainly possible, although far from confirmed." (19)

In their study, Midgley and his collaborators raise some important caveats to the notion of a steroid dependence syndrome. Reporting that the vast majority of users said their reason for using AS was to increase their size, and only two mentioned a "mental high" as a reason for use, the authors cast doubt on the psychoactive properties of AS. (20) In their view, AS dependence is more likely caused by "secondary reinforcing effects" than by a primary psychoactive stimulation of the brain. That is, the effects of AS on the body are personally and socially rewarding and encourage continued use. Users do report euphoria, but rather than intoxication, as found in alcohol or cocaine use, for example, this again is a response to increases in size and strength. Stopping AS use leads to loss of size or strength, which results in symptoms of depression, low self-esteem and craving.

What is of interest here is that either neurological or social-reward mechanisms can be used to convincingly explain the same behavior and experience of compulsion, loss of control, and withdrawal. Thus for those concerned with the addictive experience and problems faced by users, the distinction between primary and secondary reinforcement is a somewhat abstract matter. But from another perspective, determining whether neurological or social rewards drive AS use is highly significant because at stake is the status of AS as psychoactive substances. The DSM criteria are for psychoactive substance dependence, so no matter how many symptoms of dependence are produced by a substance, it cannot be dependence if the substance itself does not meet certain criteria. (21)

This highlights a tension in the DSM classification system. The adoption of DSM-III in 1980 by the American Psychiatric Association was heralded as a major shift in psychiatry toward scientific medicine and away from psychoanalysis. The most distinguishing and celebrated feature of the new classification system was its supposedly atheoretical and descriptive approach. Avoiding etiological explanations, it "attempts to describe in behavioral terms criteria which must be present for each diagnostic category." (22) But in the case of substance dependence, there is an etiological presumption that dependence is caused by the particular neurochemical effects of a substance. This presumption could also be viewed as a theoretical position on dependence. Symptoms of impaired control, harmful consequences, preoccupation and withdrawal associated with compulsive sexual activity, habitual Internet use, overeating, or an excessive commitment to one's work do not qualify as dependence under this scheme because the objects of addiction do not qualify as genuinely addictive.

Ambiguity about the distinguishing features of dependence is also found in the ICD-10. Steroids, along with laxatives, nonprescription painkillers, and antidepressants, are described as psychotropic drugs that do not produce dependence. Abuse of these drugs is distinguished from abuse of psychoactive drugs because although "the patient has a strong motivation to take the substance, no dependence or withdrawal symptoms develop." (23) But how different is "a strong motivation to take the substance" from "a strong desire to take the substance," the first diagnostic criterion listed for substance dependence in the ICD-10? (24) Given the presence of "strong motivation," the statement that no symptoms of dependence develop is surprising. This suggests that it is the existence of a withdrawal syndrome that is being used to distinguish between nondependence-producing and dependence-producing substances, which is inconsistent with the recognition that withdrawal is not a necessary symptom of dependence.

At issue, then, is a larger question about the nature of addiction and, specifically, the range of potential objects of addiction. There are many researchers and writers in the field who challenge the emphasis on the psychoactive substance as the agent of addiction, and who would argue that if a patient acts addicted, he is addicted. For critics of medical models of addiction, such as psychologist Stanton Peele, addiction is a habitual style of coping with the world, the result of a social learning process rather than a response to the chemical properties of particular substances. Thus potential objects of addiction include any activity or experience that enables users to achieve desired states of mind or being. (25) From this perspective, the ability of AS use to cause dependence does not prove that they belong to a special category of dependence-producing psychoactive substances; rather, it demonstrates that addictive attachments can be formed to any powerful or intense experience.

Another challenge to the view that dependence is the exclusive domain of psychoactive substances is mounted by advocates of non-substance-related compulsive disorders such as sex addiction, food addiction, and exercise addiction. Not only have self-help groups, therapists and popular writers supported the existence of such addictions, but medical and health professionals have given these new disorders a certain (contested) legitimacy, producing detailed accounts of cases, symptoms, etiology and treatment. To counter scepticism about the authenticity of these addictions, their supporters can demonstrate how afflicted individuals meet the DSM criteria for dependence. For example, case studies quoted in sex addiction texts provide vivid illustrations of preoccupation, impaired control, and harmful consequences. (26) For example, a married businessman is unable to control his urge to visit massage parlors and prostitutes despite knowing that he risks disease and arrest. His job performance suffers because of the many hours he spends pursuing and thinking about sex, as do his marriage and his finances.

In response to the expansion of "addiction" to refer to "non-chemical" activities such as sex, gambling, and Internet use, some addiction psychiatrists have argued that such broad use of the term runs the danger of "trivializing dependence" as well as minimizing significant differences between repetitive behaviors. (27) More strongly, others have argued that addiction should be restricted to substance use because of the particular power of drugs to influence behavior. Arguing against including "nondrug disorders" in the addiction category, psychiatrist Norman Miller emphasizes the distinct "foreign" and "pharmacological" effects drugs have on the brain and behavior and the ability of drug-brain-receptor interactions to produce stereotypical and predictable responses in mood, cognition and behavior. (28) Recent brain-imaging studies and other neuroscientific research that links changes in neurochemistry and brain activity to cocaine and opiate abuse and addiction have given such arguments about the uniqueness of drugs increased authority. (29)

However, advocates of non-drug addictions are also able to draw on the explanatory power of neurochemistry to explain these troubling experiences of compulsion. In the case of pathological gambling, currently defined as an impulse disorder, neuroscientific research has found evidence of changes in brain function similar to those seen in response to euphoria-producing drugs. (30) In the popular self-help literature on sex and food addiction, authors commonly argue that craving, withdrawal and tolerance are experienced in these addictions, in part through a mechanism of psychological dependence, but also because the endorphins and other neurotransmitters released by sexual behavior and the consumption of certain foods can produce physiological dependence. (31)

The notion of endorphin addiction is easily dismissed as unproved speculation, but it does suggest a different view of AS dependence. If it is agreed that AS cause dependence but are not a psychoactive substance, it could be that the disorder is more like an addiction to a euphoria-producing activity than dependence on a substance. Midgley et al. make a similar point when they observe that AS use always takes place with training, and that "Training could ... have greater psychoactive properties than AS use by producing noradrenic effects on the brain." (32) This suggests a curious configuration where the activity (intense exercise) is the addictive "substance" and the substance (AS) is the "substance-related activity." Recognizing the possibility that the activity rather than the substance is the primary agent of compulsion keeps open the question of what other non-substance-related activities may be addictive.

What kind of dependence?

The previous section suggested that although there was evidence of AS dependence as a clinical phenomenon, there is uncertainty and debate about whether AS produce dependence in a similar way to psychoactive drugs such as cocaine and opiates. However, closer examination of the practice of AS use reveals that AS abuse and dependence also tends to diverge significantly from generic models of substance dependence in terms of behavioral and subjective criteria.

The point that different drugs are likely to have different patterns of use, abuse and dependence is relevant not only to AS. In fact, flexibility and broadness are outstanding characteristics of the DSM "dependence syndrome." The radically disjunctive nature of diagnosis according to the DSM model allows problems as varied in their manifestations as nicotine addiction, heroin addiction and addiction to hallucinogens to be included under the same classification. As Robin Room has observed, if meeting any three of the criteria qualifies as dependence, then many different forms of dependence exist. Some of these subtypes will have no overlap in their constituent criteria, and there is no single criterion that is necessarily shared by all who are "dependent." (33)

Within this broad categorization, investigation of the way that AS users meet specific DSM criteria reveals a significant awkwardness of fit. Firstly, as Midgley et al. point out, increasing the dose of AS can be interpreted as a demonstration of impaired control over use. (34) However, a pattern of cycling on and off steroids is the main feature of AS use. Cycling is seen by users as a way of maximizing benefits and minimizing side effects, as tolerance is believed to build up after a certain point. This pattern of use, in which the substance is used for a predetermined period, then stopped, suggests control rather than lack of control, even if there is a long-term increase in the amount of AS used. Ethnographic and sociological studies have found that AS use is often an instrumental activity that is "carefully planned, monitored and adjusted," with close attention paid to correct dosages. (35) This is not to deny that users may experience difficulty in stopping or decreasing their AS use, but what impaired control looks like in a context of instrumental rationality needs to be considered.

The practices of "pyramiding" and "stacking" within cycles further complicate the picture. Pyramiding refers to gradually increasing doses up to a certain level, followed by a tapering back to the base level. Stacking refers to combining multiple types of AS in one cycle in order to increase and improve the muscle-building effects. While increasing doses and simultaneous use of multiple substances can appear to signify impaired control, in AS use such patterns could just as likely be a planned strategy of use. A shift from oral steroids to injectables, as found in the case described by Hays et al., also suggests an increasing commitment to drug use, echoing as it does a move from "soft" to "hard" drugs. This may be the case, but it is well known that injectable steroids are less toxic to the liver than oral preparations. The move to injection could therefore be considered a rational attempt to reduce harm rather than an element of escalating use.

Midgley et al. also note that the criterion of the replacement of social, work or leisure activities by drug use is of questionable salience in AS use. (36) As they remark, it would be impossible to replace social, work and leisure activity with a weekly injection and daily tablet use. In fact, AS use is intimately enmeshed with the activity of weight training (which could be classified as a social, work or leisure activity), and it in fact enables and promotes this activity. Rather than taking users away from their training, AS use enables them to train harder and longer. Moreover, for those in occupations that require a muscular physique and strength (such as modeling, policing, construction and security work), AS use could enhance rather than hinder employment performance and career prospects.

The criterion regarding amount of time spent on substance-related activity is also interestingly configured in relation to AS use. The obvious substance-related activity is training; it is certainly the case that AS users spend a great deal of time working out, but the gym was probably a central and time-consuming feature of their lives prior to AS use. This criterion is commonly expressed as "a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects." This does not capture the intimate relationship between AS and weight training, which combines, along with diet, into a specific and coherent bodily practice and an embodied project of self-production.

Withdrawal as a feature of AS dependence has a particular significance because it is regarded as a symptom of physiological dependence. Generally, physical dependence is understood to describe the physiological adaptation of the body to chronic use of a substance, as demonstrated by withdrawal symptoms and tolerance. Psychological dependence is taken to describe the urge or desire to take the drug despite adverse consequences. Although this distinction seems relatively straightforward, it is in fact difficult to clearly separate physical and psychological dependence either conceptually or as elements of the addictive experience. Surgical patients treated for pain may be physiologically adapted to the presence of opiates, but in the absence of the urge to continue use, or indeed the recognition that they are dependent, it is unclear whether they are dependent in the broader sense. Moreover, the sensitivity of withdrawal symptoms to factors such as memory, anticipation, experience and environment is evidence of the enmeshment of the physiological and psychological.

Although in the DSM withdrawal and tolerance are given no more weight than other symptoms and are therefore not the defining features of the dependence syndrome, the idea that physical dependence on a drug is the sign of genuine addiction remains in circulation. For example, a college textbook on substance abuse uses "a demonstrated withdrawal syndrome" as the criterion that indicates whether a user is "actually addicted to a chemical." (37) The emphasis on physical dependence helps produce substance dependence as a firmly scientific and medical matter, and acts to refute arguments that value-laden and subjective judgments are the basis of diagnosis.

Following the standard equation of withdrawal with physical dependence, work on AS tends to interpret reports of withdrawal symptoms as evidence of the physiological addictiveness of AS. But the withdrawal symptoms commonly reported with AS use are quite different in kind from those round in more established and well-known withdrawal syndromes. Symptoms such as the nausea, rhinitis, diarrhea, muscle aches, and goose bumps of heroin withdrawal are understood as the result of the body's attempt to maintain physiological homeostasis. The major withdrawal symptoms reported in AS use are desire to take more steroids, fatigue, depression, and body-image dissatisfaction or feeling "not big enough." To what extent can such symptoms be linked to physiological and neurological processes of adaptation? The symptoms of physical dependence on AS appear to be principally psychological, or secondary rather than primary, to return to Brower's typology. Given that AS lead to improvements in physique and ability to endure intense training, it is not surprising that users who stop feel frustration, anxiety and a desire to restart use, but it is debatable whether these feelings, powerful as they may be, should be regarded as withdrawal.

Lack of clarity about different elements of dependence is in part caused by conceptual slippages and shifting terminology. Substance withdrawal causing clinically significant distress is understood as an aspect of physical dependence, but withdrawal is also used to describe any negative effects that occur after stopping substance use. Thus it becomes possible for symptoms such as unhappiness with one's physique to be taken as evidence of physiological adaptation of the body to a drug. A similar slippage occurs when the construct "craving" is used to describe a desire for the substance. Craving suggests a particularly intense and pathological desire, distinct from ordinary wanting and with the connotation of an underlying physiological disturbance. However, it is also used to refer to any desire for a drug. The difficulties of conceptualizing and assessing craving and the continuing disagreements about what craving is, how to measure it, its connection to drug use, and even its validity as a topic for scientific study have been extensively discussed. (38) Indeed the phenomenon craving has recently been described as "an enduring puzzle." (39) In the AS literature, references to steroid craving connote a physiological need, but often the term is used simply as a synonym for "the desire to take more steroids." Similarly, the term euphoria suggests a direct and immediate psychoactive "high," but is also used to describe the pleasure, exhilaration and well-being that users report after long-term use. These terminological and conceptual issues are by no means specific to AS, but accounts of AS use are illustrative of the conceptual vagueness that can plague discussions of dependence. It can be argued that this vagueness has a certain usefulness because it allows a wide range of different drug problems to be recognized and diagnosed. But as Room has observed, it can also obscure important differences between drugs, (40) thereby promoting inappropriate drug policies and health and education programs.

Conclusion

Although clinical and survey data support the existence of dependence on AS, there are problems with the notion of an AS dependence syndrome based on DSM guidelines. These include both the questionable status of AS as psychoactive drugs and the distinctive nature of AS use as an element in a structured project of bodily enhancement. Even though AS use may fulfill the criteria for a diagnosis of substance dependence, it is important to pay attention to the specificities of these drugs and their patterns of use rather than viewing them through a generic framework of "illicit drug abuse." AS users themselves do not identify as drug users, and some groups of users at least are characterized by health consciousness, high educational and occupational levels, and low levels of recreational and social drug use. (41) Therefore issues such as the risks of HIV transmission with AS use and the operation of AS as "gateway" drugs leading to other forms of illicit drug use need to be carefully investigated rather than assumed to be similar to patterns round with other drugs.

Moving beyond the research discussed in this paper, the question of whether AS are addictive is closely linked to public and medical concern about the increasing illicit use of these drugs, especially by young people. Addiction is seen as one of the potential harms of AS use, but there is also the sense that because AS use is a serious drug-abuse problem and AS are dangerous and powerful substances, AS must be addictive. In contemporary discourses on drugs, it can be difficult to separate harmfulness from addictiveness. The presumption that individuals are rational and autonomous means that if they persist in an activity that is obviously causing them harm, then some disorder of the will must be present. One of the problems with this logic of addiction is that it seems almost inevitable that any substance shown to cause harm (or even linked to potential harm) will be identified as addictive. In their broadness, the DSM diagnostic criteria enable almost any intense and habitual activity that others might disapprove of to provide evidence of dependence.

Harmfulness is also linked to addictiveness because addiction is viewed as a significant harm in itself, independent of its medical and social consequences. While the conduct associated with the most visible addictions undeniably enhances addiction's bad reputation, it is also seen as bad in itself because it destroys or reduces individual freedom. This negative evaluation is apparent in the underuse and underprescription of opioid analgesics for pain relief in cancer and HIV/AIDS and in other conditions causing severe chronic pain such as migraine headache and osteoporosis. Fear of addiction among both health professionals and patients is recognized as one of the most important factors in the undertreatment of pain. (42) The perception of addiction as bad in itself was also seen in the opposition of some health professionals to the public availability of a nicotine inhaler, which reproduces many of the desired effects of smoking without the usual harmful effects caused by smoke, tar and other carcinogens. The concern was that the inhaler could encourage addiction to nicotine. (43)

Given the powerful social meanings attached to addiction, classifying a substance as addiction-producing is likely to have significant effects. These could include pressure for increased control of the substance (already seen with AS), increased pathologization and criminalization of users, and increased reluctance to utilize the substance for clinical purposes. In view of the conceptual vagueness and elasticity of the dependence concept, these kinds of social consequences, whether desirable or undesirable, should also be considered in debates about addictiveness.

DSM-III-R diagnostic criteria for psychoactive substance dependence *

1. The substance is often taken in larger amounts or over a longer period than intended.

2. There is a persistent desire to cut down or unsuccessful efforts to control substance use.

3. A great deal of time is spent in getting the substance, taking it, or recovering from it.

4. Frequent intoxication or withdrawal symptoms are experienced when the user is expected to fulfill major obligations at work, school or home or when substance use is hazardous.

5. Important social, occupational or recreational activities are given up or reduced because of substance use.

6. Substance use continues despite persistent or recurrent social, psychological or physical problems caused by the substance.

7. A marked tolerance develops and a need for markedly increased amounts of the substance to achieve the desired effect, or there is a markedly diminished effect with continued use of the same amount.

8. Characteristic withdrawal symptoms are experienced.

9. The substance is taken to relieve or avoid withdrawal symptoms.

* In DSM-IV criteria 8 and 9 were combined and criterion 4 was omitted.

SOURCE: American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd edn., rev.: DSM-III-R. Washington DC: American Psychiatric Association, 1987.

Notes

(1.) Yesalis C.E., Bahrke M.S., Kopstein A.N., Barsukiewicz C.K. (2000). Incidence of anabolic steroid use: A discussion of methodological issues. In Yesalis C.E. (ed.), Anabolic steroids in sport and exercise. 2nd edn. Champaign, IL: Human Kinetics, 73-115, pp. 105, 106.

(2.) Higgins K., Cooper-Stanbury M., Williams P. (2000). Statistics on drug use in Australia 1998. Canberra: Australian Institute of Health and Welfare.

(3.) Ireland K., Southgate E., Knox S., Van de Ven P., Howard J., Kippax S. (1999). Using and "the scene": Patterns and contexts of drug use among Sydney gay men. Sydney: National Centre in HIV Social Research.

(4.) Lovstakken K., Peterson L., Homer A.L. (1999). Risk factors for anabolic steroid use in college students and the role of expectancy. Addictive Behaviors 24(3): 425-30, p. 425.

(5.) American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, 4th edn., text revision: DSM-IV-TR. Washington DC: American Psychiatric Press, p. 294.

(6.) World Health Organization (1993). The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva: World Health Organization, pp. 21-22.

(7.) Kleinman C.C., Petit C.E. (2000). Legal aspects of anabolic steroid use and abuse. In Yesalis, C.E. (ed.), Anabolic steroids in sport and exercise. 2nd edn. Champaign, IL: Human Kinetics, 333-359, p. 344. The differences between the model of dependence round in the Controlled Substances Act and the clinical model of substance dependence (expressed in the AMA's objection) are noteworthy. In the clinical model, social consequences and individual impairment are emphasized, while the CSA focuses on tolerance and withdrawal, utilizing an understanding of addiction that much medical opinion would regard as out of date. Thank you to the anonymous reviewer who pointed this out.

(8.) See, for example, Room R. (1985). Dependence and society. British Journal of Addiction 80: 133-39; Levine H. (1978). The discovery of addiction: Changing conceptions of habitual drunkenness in America. Journal of Studies on Alcohol 39(1): 143-74; Valverde M. (1998). Diseases of the will: Alcohol and the dilemmas of freedom. Cambridge: Cambridge University Press; Peele, S. (1998). The meaning of addiction: An unconventional view. San Francisco: Jossey-Bass.

(9.) DSM-IV was published in 1994, and with no new DSM anticipated until 2010 or later, a text revision of DSM-IV was published in 2000 in order to maintain the manual's currency. Most of the significant revisions were in the descriptive text, with only a few changes in diagnostic criteria. The text and criteria related to AS remained the same as in DSM-IV.

(10.) Hays L.R., Littleton S., Stillner V. (1990). Anabolic steroid dependence (letter). American Journal of Psychiatry 147(1): 122.

(11.) Brower K.J., Blow F.C., Beresford T.P., Fuelling C. (1989). Anabolic-androgenic steroid dependence. Journal of Clinical Psychiatry 50: 31-33, p. 32.

(12.) Brower K.J., Eliopulos G.A., Blow F.C., Catlin D.H., Beresford T.P. (1990). Evidence for physical and psychological dependence on anabolic androgenic steroids in eight weight lifters. American Journal of Psychiatry 147(4): 510-12; Brower K.J., Blow F.C., Young J.P., Hill E.M. (1991). Symptoms and correlates of anabolic-androgenic steroid dependence. British Journal of Addiction 86: 759-68.

(13.) Brower et al., Symptoms and correlates, supra note 12.

(14.) Brower K.J. (2000). Anabolic steroids: Potential for physical and psychological dependence. In Yesalis, C.E. (ed.), Anabolic steroids in sport and exercise. 2nd edn. Champaign, IL: Human Kinetics, 279-304, pp. 287-8.

(15.) Midgley S.J., Heather N., Davies J.B. (1999). Dependence-producing potential of anabolic-androgenic steroids. Addiction Research 7(6): 539-50.

(16.) Brower, supra note 14, p. 290; Brower, K.J. (1992). Anabolic steroids: Addictive, psychiatric, and medical consequences. The American Journal on Addictions 1(2): 100-114, p. 104.

(17.) Yesalis C.E., Vicary W.E., Buckley W.E., Streit A.L., Katz D.L., Wright J.E. (1990). Indications of psychological dependence among anabolic-androgenic steroid abusers. National Institute on Drug Abuse Research Monograph Series 102, 196-214, p. 207.

(18.) Kashkin K.B., Kleber H.D. (1989). Hooked on hormones?: An anabolic steroid addiction hypothesis. Journal of the American Medical Association 262(22): 3166-70.

(19.) Brower, supra note 14, p. 292.

(20.) Midgley et al., supra note 15.

(21.) In DSM-IV and DSM-IV-TR there is no explicit requirement that dependence-producing substances be psychoactive; however, as already mentioned, the steroid literature tends to use the earlier version of the DSM and maintains the view that psychoactivity is a crucial issue. Moreover, much of the literature discussing and employing DSM-IV continues to regard the substances in question as invariably psychoactive. See, for example, Morrison J. (1995). DSM-IV made easy: The clinician's guide to diagnosis. New York: Guilford Press.

(22.) Kirk S.A., Kutchins H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine de Gruyter.

(23.) World Health Organization, supra note 6, p. 122.

(24.) I was alerted to this point by Robin Room.

(25.) Peele, supra note 8.

(26.) See Schneider J. (1991). How to recognize the signs of sexual addiction. Postgraduate Medicine 90(6): 171-82; Earle R., Earle M. (1995). Sex addiction: Case studies and management. New York: Brunner/Mazel. Carnes P. (1989). Contrary to love: Helping the sexual addict. Minneapolis: CompCare.

(27.) Jaffe J. (1990). Trivializing dependence. British Journal of Addiction 85: 1425-27.

(28.) Miller N. (1995). Addiction psychiatry: Current diagnosis and treatment. New York: Wiley-Liss, pp. 19, 24.

(29.) See, for example, Volkow N., Wang G., Fowler J. (1997). Imaging studies of cocaine in the human brain and studies of the cocaine addict. In Lester D., Felder C., Lewis E. (eds.), Imaging brain structure and function: Emerging technologies in the neurosciences, Annals of the New York Academy of Sciences, vol. 820, New York: New York Academy of Sciences; Childress A.R., Mozley P.D., McElgin W., Fitzgerald J., Reivich M., O'Brien, C. (1999). Limbic activation during cue-induced cocaine craving. American Journal of Psychiatry 156(1): 11-18; Childress A.R., McElgin W., Mozley P.D., Reivich M., O'Brien, C. (1996). Brain correlates of cue-induced cocaine and opiate craving, Society for Neuroscience Abstracts 22(2): 933.

(30.) Breiter H., Aharon I., Kahneman D., Dale A., Shizgal P. (2001). Functional imaging of neural responses to expectancy and experience of monetary gains and losses. Neuron 30: 619-39; Shaffer H. (1999). Editorial: Strange bedfellows: A critical view of pathological gambling and addiction. Addiction 94(10): 1445-48, p. 1446.

(31.) Griffin-Shelley E., Sex and love: Addiction, treatment and recovery. New York: Praeger; Katherine A. (1997). Anatomy of a food addiction: The brain chemistry of overeating, 3rd edn. San Francisco: Gurze.

(32.) Midgley et al., supra note 15, p. 548.

(33.) Room R. (1998). Alcohol and drug disorders in the International Classification of Diseases: A shifting kaleidoscope. Drug and Alcohol Review 17: 305-17, p. 313.

(34.) Midgley et al., supra note 15, p. 547.

(35.) Bloor M., Monaghan L., Dobash R.P., Dobash R.E. (1998). The body as a chemistry experiment: Steroid use among South Wales bodybuilders. In Nettleton S., Watson J. (eds.), The body in everyday life. London: Routledge 27-44, p. 28.

(36.) Midgley et al., supra note 15, p. 548.

(37.) Doweiko H.F. (1993). Concepts of chemical dependency, 2nd edn. Pacific Grove: Brooks/Cole Publishing, p. 8.

(38.) See Kozlowski L., Wilkinson D.A. (1987). Use and misuse of the concept of craving by alcohol, tobacco and drug researchers. British Journal of Addiction 82: 31-36, for a thoughtful discussion of the problems with craving as a term in drug research. See also Addiction (2000) 95 (Supplement 2), which is devoted to research papers and commentaries on craving, especially in relation to alcohol.

(39.) Drummond D.C., Litten R., Lowman C., Hunt W. (2000). Craving research: Future directions. Addiction 95 (Supplement 2): S247-S255, p. S247.

(40.) Room, supra note 33, p. 314.

(41.) Peters R., Copeland J., Dillon P., Beel A. (1997). Patterns and correlates of anabolic-androgenic steroid use. National Drug and Alcohol Research Centre Technical Report no. 48. Sydney: NDARC.

(42.) Colleau S., Joranson D. (1998). Fear of addiction: Confronting a barrier to cancer pain relief. Cancer Pain Release 11(3), online: [http://www.medsch.wisc.edu/WHOcancerpain/volumes/11_3/fear. html], accessed May 3, 2001; Breitbart W., McDonald, M. (1996). Pharmacologic pain management in HIV/AIDS. Journal of International Association of Physicians in AIDS Care, July, online: [http:www.iapac.org/clinmgt/painmgt/painmgt.html], accessed May 3, 2001.

(43.) This case is discussed in Oddie G. (1993). Addiction and the value of freedom. Bioethics 7(5): 373-401, as part of a philosophical argument against the "intrinsic disvalue" of addiction.

HELEN KEANE is on the staff of the Centre for Women's Studies, School of Humanities, Australian National University (Canberra, ACT 0200, Australia; Helen.Keane@anu.edu.au). Her research interests are in cultural studies of health and medicine, especially related to drugs, substance use and addiction, chronic illness, reproduction, self-help and popular psychology; feminist theory; theories of the body; and science and technology studies, especially related to drugs and biomedical technology. She is the author of What's Wrong with Addiction (2002).
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